Abstract
BackgroundCryptococcal disease is estimated to be responsible for significant mortality in Sub-Saharan Africa; however, only scarce epidemiology data exists. We sought to evaluate the prevalence of and risk factors for cryptococcal antigenemia in Ethiopia.MethodsConsecutive adult HIV-infected patients from two public HIV clinics in Addis Ababa, Ethiopia were enrolled into the study. A CD4 count ≤200 cells/μl was required for study participation. Patients receiving anti-retroviral therapy (ART) were not excluded. A cryptococcal antigen test was performed for all patients along with an interview, physical exam, and medical chart abstraction. Logistic regression analysis was used to assess risk factors for cryptococcal antigenemia.Results369 HIV-infected patients were enrolled; mean CD4 123 cells/μl and 74% receiving ART. The overall prevalence of cryptococcal antigenemia was 8.4%; 11% in patients with a CD4 count <100 cells/μl, 8.9% with CD4 100 to 150 cells/μl and 5.7% with CD4150-200 cell/μl. 84% of patients with cryptococcal antigenemia were receiving ART. In multivariable analysis, increasing age, self reported fever, CD4 count <100 cells/μl, and site of screening were associated with an increased risk of cryptococcal antigenemia. No individual or combination of clinical symptoms had optimal sensitivity or specificity for cryptococcal antigenemia.ConclusionCryptococcal antigenemia is high in Ethiopia and rapid scale up of screening programs is needed. Screening should be implemented for HIV-infected patients with low CD4 counts regardless of symptoms or receipt of ART. Further study into the effect of location and environment on cryptococcal disease is warranted.
Highlights
Increasing access to antiretroviral therapy (ART) has transformed the prognosis of HIV-infected patients in resource-limited settings
The high burden of opportunistic infections remains an enormous challenge to optimal HIV care and in resource-limited settings (RLS), patients continue to die of HIV-related opportunistic infections (OIs) in the weeks prior to, and months following initiation of ART
Two patients had a prior history of cryptococcal disease (1%) in contrast to a high prevalence of prior pulmonary (25%) and extra pulmonary tuberculosis (9%)
Summary
Increasing access to antiretroviral therapy (ART) has transformed the prognosis of HIV-infected patients in resource-limited settings. The high burden of opportunistic infections remains an enormous challenge to optimal HIV care and in resource-limited settings (RLS), patients continue to die of HIV-related opportunistic infections (OIs) in the weeks prior to, and months following initiation of ART. Recent reports highlight the alarming issue of cryptococcal meningitis (CM) in Sub-Saharan Africa (SSA) and make it clear that there is still much to be done to improve the diagnosis and management of CM [2,3]. Cryptococcal disease is estimated to be responsible for significant mortality in Sub-Saharan Africa; only scarce epidemiology data exists. We sought to evaluate the prevalence of and risk factors for cryptococcal antigenemia in Ethiopia
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